Patient dignity and privacy
85 items
2 sources
Failure to ensure suitable arrangements are in place to consider and respect the dignity, privacy, and independence of people using care services.
Cross-Source Insight
Patient dignity and privacy has been flagged across 2 independent accountability sources:
71 inquiry recs
14 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (71)
BRIS-1 — Ensure patient involvement in all treatment and care decisions
Recommendation: In a patient-centred healthcare service patients must be involved, wherever possible, in decisions about their treatment and care.
Unknown
BRIS-10 — Provide NHS tape-recording facilities for patients to record healthcare discussions
Recommendation: Tape-recording facilities should be provided by the NHS to enable patients, should they so wish, to make a tape recording of a discussion with a healthcare professional when a diagnosis, course of treatment, or prognosis is being discussed.
Unknown
BRIS-102 — Ensure patients are informed about innovative procedures and clinician experience
Recommendation: Patients are always entitled to know the extent to which a procedure which they are about to undergo is innovative or experimental. They are also entitled to be informed about the experience of the clinician who is to carry out …
Unknown
BRIS-11 — NHS employers must ensure staff allow patients time for questions
Recommendation: Patients should always be given the opportunity and time to ask questions about what they are told, to seek clarification and to ask for more information. It must be the responsibility of employers in the NHS to ensure that the …
Unknown
BRIS-12 — Provide patients with information enabling active participation in their care decisions.
Recommendation: Patients must be given such information as enables them to participate in their care.
Unknown
BRIS-13 — Provide patients with pre-procedure explanation and post-procedure review opportunity.
Recommendation: Before embarking on any procedure, patients should be given an explanation of what is going to happen and, after the procedure, should have the opportunity to review what has happened.
Unknown
BRIS-15 — Inform patients they can have a chosen person present when receiving information
Recommendation: Patients should be told that they may have another person of their choosing present when receiving information about a diagnosis or a procedure.
Unknown
BRIS-16 — Empower patients to decline information, requiring skilled healthcare professional communication
Recommendation: Patients should be given the sense of freedom to indicate when they do not want any (or more) information: this requires skill and understanding from healthcare professionals.
Unknown
BRIS-187 — Recognise parents as experts and fully involve them in their children's healthcare
Recommendation: Parents should ordinarily be recognised as experts in the care of their children, and when their children are in need of healthcare, parents should ordinarily be fully involved in that care.
Unknown
BRIS-188 — Value and incorporate parents' knowledge of very young children into care
Recommendation: Parents of very young children have particular knowledge of their child. This knowledge must be valued and taken into account in the process of caring for the child, unless there is good reason to do otherwise.
Unknown
BRIS-189 — Answer children's questions about their care truthfully and clearly
Recommendation: Children’s questions about their care must be answered truthfully and clearly.
Unknown
P1-17 — Deceased treated with same dignity as patients
Recommendation: Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does its other patients.
Gov response: Implemented. The Trust has embedded this principle in policy and practice. The deceased are now afforded the same safeguarding and dignity considerations as living patients. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial …
Accepted
Delivered
P1-2 — No deceased left out of fridges overnight
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that all regulatory requirements and standards relating to the mortuary are met and that the practice of leaving deceased people out of mortuary fridges overnight, or while maintenance is undertaken, does …
Gov response: Implemented. The Trust has confirmed compliance with this requirement. Standard Operating Procedures updated to ensure deceased persons are not left out of fridges unnecessarily. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement …
Accepted
Delivered
P1-6 — Review policies on mortuary access
Recommendation: Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.
Gov response: Implemented. Policies have been reviewed and updated. Access is now controlled via individual swipe cards with appropriate restrictions. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-9 — CCTV in mortuary including post-mortem room
Recommendation: Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.
Gov response: Implemented. Full CCTV coverage has been installed throughout the mortuary including the post-mortem room, with appropriate safeguards for dignity. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P2-1 — NHS trusts commission specialist security review
Recommendation: All NHS trusts with mortuaries and/or body stores should commission a specialist strategic review of the systems in place to protect deceased people, which should include a detailed risk assessment of the potential breaches of security that could occur. The …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-19 — Deceased included in safeguarding training and policy
Recommendation: NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-2 — CCTV in all NHS mortuaries
Recommendation: All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the doors of body fridges, while maintaining the security and dignity of deceased people by implementing the appropriate safeguards. …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-20 — Chief Nurse responsibility for deceased safeguarding
Recommendation: The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-21 — NHS England incorporate deceased in safeguarding framework
Recommendation: NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-22 — Independent sector SOPs for deceased patients
Recommendation: Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity of any patients that die under their care. Wherever possible, deceased patients' rooms should be kept locked. Providers …
Gov response: The Department of Health and Social Care has met with the Independent Healthcare Provider Network (IHPN), who engaged with its members in September 2025. IHPN members have confirmed they have taken action on the report, …
Accepted
In progress
P2-23 — Independent sector accompanied access to deceased
Recommendation: Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased patient do so, even if they are staff members, and that they are always accompanied.
Gov response: The Department of Health and Social Care has met with the Independent Healthcare Provider Network (IHPN), who engaged with its members in September 2025. IHPN members have confirmed they have taken action on the report, …
Accepted
In progress
P2-24 — Anatomical education security and dignity policies
Recommendation: All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the security and dignity of donors. These should include: security and access policies and the auditing of security and …
Gov response: This recommendation is under consideration.
Response Unclear
In progress
P2-25 — Postgraduate training governance clarity
Recommendation: Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue …
Gov response: This recommendation is under consideration.
Response Unclear
P2-26 — HTA require anatomy adverse incidents reported as HTARIs
Recommendation: The Human Tissue Authority should change its guidance to require that relevant adverse incidents in the anatomy sector are formally reported as Human Tissue Authority Reportable Incidents (HTARIs).
Gov response: The Human Tissue Authority has expanded the scope of its adverse events and reportable incidents systems in the Post-Mortem sector to include the Anatomy sector. The HTA has issued formal guidance to ensure that adverse …
Accepted
Delivered
P2-27 — Hospice security and access controls
Recommendation: Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; have Standard Operating Procedures regarding the care of deceased people, including security of and access to the areas …
Gov response: The Department of Health and Social Care has worked with Hospice UK to ask its clinical leaders group network to urgently review their clinical practices against the recommendations. Hospice UK has already updated its Care …
Accepted
In progress
P2-28 — CQC guidance on hospice inspection scope
Recommendation: To avoid confusion over its remit, the Care Quality Commission should issue clear guidance to inspectors (and others) that hospice inspections should not include areas where deceased people are kept, other than to focus on the needs of bereaved relatives.
Gov response: The Care Quality Commission (CQC) issued a rapid update to reiterate to inspectors the limits of their regulation in relation to mortuaries, and a further update via its internal bulletin to inspectors. CQC is currently …
Accepted
In progress
P2-29 — Hospices in scope for new regulatory regime
Recommendation: Hospices should be considered in scope for the regulatory measures recommended in Chapter 11.
Gov response: This recommendation is under consideration.
Response Unclear
P2-3 — Audit access data for deceased storage
Recommendation: All NHS trusts should routinely audit the access data of all facilities used to store deceased people.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-30 — Ambulance data on conveying deceased
Recommendation: Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to NHS England, and monitored to assess risk.
Gov response: NHS England has confirmed that relevant data lines are in the information standard with the first routine collection expected to be rolled out in 2026/27.
Accepted
In progress
P2-31 — Ambulance policy on crew position with deceased
Recommendation: Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of deceased patients, as well as training requirements.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …
Accepted
In progress
P2-32 — Ambulance policies on deceased security and dignity
Recommendation: NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered and/or secured. NHS England should monitor that such policies are in place.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …
Accepted
In progress
P2-33 — Ambulance photography policies
Recommendation: Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may be required, and ensure that ambulance staff are aware of these and comply with them.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …
Accepted
In progress
P2-34 — Recommendations apply to independent ambulances
Recommendation: The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also be applied to independent ambulance services, including private ambulances.
Gov response: The Association of Ambulance Chief Executives (AACE) has made the Independent Ambulance Association (IAA) aware of the Inquiry recommendations. Where ambulance services have contractual agreements with independent ambulance services, those commissioned services must comply with …
Accepted
In progress
P2-35 — Local authority mortuary access review
Recommendation: There should be a process to routinely review who is permitted to access the mortuary unsupervised.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-36 — Local authority individualised access controls
Recommendation: Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary and restrict access to specific areas of the mortuary, such as the post-mortem room. There should be a …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-37 — Local authority visitor supervision
Recommendation: Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must be limited to specific areas required for the purposes of their work or visit. They must be supervised …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-38 — Local authority lone working review
Recommendation: Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration of activities involving direct handling of the deceased, alongside mitigations that can be put in place to safeguard …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-39 — Local authority security audits
Recommendation: Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, including the post-mortem room. Access data must be reconciled against CCTV footage. Audits must be reported to the …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-4 — End shared swipe cards
Recommendation: The practice of using shared electronic swipe cards for specific staff groups should cease immediately.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-40 — Local authority strategic security review
Recommendation: Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should include a detailed risk assessment of the potential breaches of security that could occur. The review should include …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-41 — No reliance on keys/keypads alone
Recommendation: There must be no reliance on keys and keypad codes alone to secure access to the mortuary.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-42 — Lock fridges and freezers at all times
Recommendation: Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-43 — Local authority CCTV installation
Recommendation: CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges containing deceased people, including where these are accessible from within the post-mortem room. Local authorities must put appropriate …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-44 — Local authority incident response SOPs
Recommendation: Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-45 — Local authority single security SOP
Recommendation: All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security Standard Operating Procedure.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-46 — Local authority funding for security expedited
Recommendation: There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited and considered at the highest levels within the local authority.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-47 — Local authority security breach investigation
Recommendation: There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority as a minimum. Serious security breaches must also be reported …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-48 — Local authority annual SOP and HTA audits
Recommendation: There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, with a clear record of authorisation by the Designated Individual, head of service or equivalent. Audits of staff …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-49 — Local authority DI management and oversight review
Recommendation: There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the mortuary, level of influence within the local authority, and attendance …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-5 — Operational barriers including device restrictions
Recommendation: All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. An example of this would be implementation of a rule that prevents electronic devices such as phones or …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-50 — Local authority mortuary as regulated service
Recommendation: The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory committee, with regular reporting. Key performance indicators must be identified …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-51 — Local authority biennial audits and peer review
Recommendation: The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal committee regardless of the level of assurance. Local authorities must arrange a peer review of the mortuary service …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-52 — Share mortuary reports with coroner service
Recommendation: All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to see these reports). Local authorities that are not the lead …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-53 — Local authority report implementation to committee
Recommendation: The implementation of these recommendations must be reported to the relevant statutory committee.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-54 — Local authority contingent body storage plans
Recommendation: Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-55 — Unlicensed body stores prepared for HTA compliance
Recommendation: Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, in the event that a Human Tissue Authority licence is required to enable activities outside Human Tissue Authority …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-56 — Unlicensed body stores follow same standards
Recommendation: Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers of licensed mortuaries.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
IHRD-10 — Age-Appropriate Hospital Settings
Recommendation: Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.
Gov response: Trusts have published policies on age-appropriate care settings for children and young people.
Accepted
Delivered
IHRD-16 — Bedside Display of Responsible Staff
Recommendation: The names of both the consultant responsible and the accountable nurse should be prominently displayed at the bed in order that all can know who is in charge and responsible.
Gov response: Name boards implemented at bedsides in children's wards across Trusts.
Accepted
Delivered
IHRD-22 — Parental Knowledge in Care Plans
Recommendation: Clinicians should respect parental knowledge and expertise in relation to a child's care needs and incorporate the same into their care plans.
Gov response: Parental involvement in care planning promoted through policy and training.
Accepted
Delivered
IHRD-23 — Care Plan Availability at Bedside
Recommendation: The care plan should be available at the bed and the reasons for any change in treatment should be recorded.
Gov response: Care plans made available at bedside. Documentation standards updated.
Accepted
Delivered
IHRD-28 — Informed Consent Documentation
Recommendation: Consideration should be given to recording and/or emailing information and advices provided for the purpose of obtaining informed consent.
Gov response: Informed consent processes reviewed and updated.
Accepted
Delivered
IHRD-41 — Publication of External Investigation Reports
Recommendation: Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.
Gov response: Publication policies for external investigation reports implemented.
Accepted
No update 2+ yrs
IHRD-44 — Post-Mortem Limitation Authorisation
Recommendation: Authorisation for any limitation of a post-mortem examination should be signed by two doctors acting with the written and informed consent of the family.
Gov response: Post-mortem authorisation procedures updated to require dual sign-off with family consent.
Accepted
Delivered
IHRD-54 — Bereavement Counselling Services
Recommendation: Professional bereavement counselling for families should be made available and should fully co-ordinate bereavement information, follow-up service and facilitated access to family support groups.
Gov response: Bereavement support services established across Trusts.
Accepted
Delivered
F238 — Communication with and about patients
Recommendation: Regular interaction and engagement between nurses and patients and those close to them should be systematised through regular ward rounds: All staff need to be enabled to interact constructively, in a helpful and friendly fashion, with patients and visitors. Where …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
17 — Improve Furness General Hospital delivery suite
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
SHI-1 — Communication strategy for patients and families
Recommendation: Health boards must ensure that in the event of any adverse situation that could affect the wellbeing of patients and their families, there is a communication strategy in place to liaise with this crucially important group. The Scottish Government should …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025. Progress update 17 September 2025: Discussions between the Scottish Government and NHS Boards are actively taking place to identify any gaps …
Accepted
In progress
AS-7 — Strip-Search Safeguards
Recommendation: Appropriate measures should be taken to ensure that minimum safeguards are in place where a detainee is to be strip-searched. These include informing a detainee as to the necessity for the strip-search and requesting his/her co-operation. Those conducting a strip-search …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
COVID-M3.2 — Visiting Restrictions Guidance
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals in the event of a future pandemic. The guidance should identify the circumstances in which visiting restrictions should …
Gov response: No formal response published by this government.
Unknown
PFD Reports (14)
Iris Carter
Concerns: A severe pressure sore developed before hospital discharge but was not properly inspected or adequately documented, indicating potential failures in skin assessment or record-keeping.
Responded
Tamara Davis
Concerns: The emergency department regularly uses corridors for patient care due to insufficient space, leading to inadequate privacy, lack of staffing, and safety concerns, especially during major incidents.
Responded
Marina Young
Concerns: In A&E, prolonged patient stays lacked timely alerts to management, care needs were inadequately assessed for complex patients, and nurses lacked essential asthma assessment knowledge without senior escalation.
Responded
Kim Stroud
Concerns: There was non-compliance with medication administration, with tablets left unsupervised for a patient with delirium, and serious failures in personal care.
Responded
Ronald Ashdown
Concerns: A hospital's internal investigation into poor patient care was critically flawed and unprofessional, as key photographic evidence was withheld, preventing proper identification of systemic failings.
Responded
George Griffiths
Concerns: A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.
Responded
Robert Walaszkowski
Concerns: A patient in extremely poor physical and mental health was unsafely transported on the floor of a secure vehicle without restraints, a practice accepted by the transport company, likely contributing to respiratory arrest.
Overdue
Mavis Lawrence
Concerns: Severe neglect in pressure area care included unchecked wounds, missing assessments, inadequate documentation, unaddressed pain, and a lack of escalation or specialist involvement.
Overdue
Agnes Sansom
Concerns: Patient record systems failed to communicate urgent information in a timely manner, and vulnerable patients were forced to share walking aids on hospital wards, creating safety risks.
Responded
Alice Dixon
Concerns: A vulnerable patient received inadequate assistance during the consent process for a scan, resulting in an unclear consent form and unaddressed communication/hearing difficulties.
Overdue
Billie Lord
Concerns: The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.
Responded
Barbara Cooke
Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Overdue
Mrs Care
Concerns: Unexplained extensive bruising, likely caused during hospital care and potentially related to hoist use, contributed to the deceased's death, with no clear explanation provided.
Overdue
Anthony Brian Flynn
Concerns: Seriously ill prisoners were inhumanely shackled during medical examinations, clinician concerns were ignored, and there was inadequate training for prison officers regarding hospital escorts and clinicians' powers over restraints.
Response: Sodexo has re-issued an operational instruction to staff regarding handling prisoner correspondence. They have also planned awareness days and a new training programme for prison officers on escort and bedwatch …
Overdue